Provider Demographics
NPI:1003572165
Name:MCCUNE, ISABEL GRUSKA
Entity Type:Individual
Prefix:
First Name:ISABEL
Middle Name:GRUSKA
Last Name:MCCUNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5741 NE GLISAN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3793
Mailing Address - Country:US
Mailing Address - Phone:971-412-6424
Mailing Address - Fax:844-440-2415
Practice Address - Street 1:5741 NE GLISAN ST STE 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3793
Practice Address - Country:US
Practice Address - Phone:971-412-6424
Practice Address - Fax:844-440-2415
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500800377Medicaid